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When is it time for a joint replacement?

Stefan Tserovski, MD

Interview with Dr. Stefan Tserovski

When is the right time for a joint replacement? How do we know when to consider arthroplasty?

Moderator: I would like to touch on the topic of arthrosis of the hip joint. A disease that affects many people in Bulgaria. Many of them know that they need an endoprosthesis. Physiotherapists and general practitioners are often asked: is it time for a change? Shall we try something else??

S.T: Hip joint endoprosthetics are used in orthopedics for advanced degenerative processes and arthrosis changes. Often this condition at an early stage is favorably influenced by conservative therapy for a long period of time: physiotherapy, analgesic drugs and others. However, in some cases, symptoms and joint function progressively worsen regardless of the measures taken. The decision to have surgery and the timing of the surgery is a personal choice. The decisive factor here is the degree of impairment in quality of life, which can only be determined by the individual patient.

In my practice, I have often met patients whose X-rays, MRI or computer tomography revealed advanced arthrosis with loss of articular cartilage. The extent of the cartilage damage does not always correlate with the patient's complaints. This means that the majority of patients with advanced arthritic joint changes do not have a pronounced functional deficit (pain and restricted movement) and thus a change in quality of life. At the same time, however, the imaging/diagnostic criteria for a surgical intervention are met.

I have also seen patients in the opposite situation: with limited cartilage damage and severe clinical symptoms. Deciding when to have surgery is all about answering the question, “How much does the condition affect quality of life?” How bad is the pain. "What activities can you no longer do? Which activities did you have to give up? And what do you want to achieve after the operation?" And the second question would be: If the hip joint was completely pain-free and you had no symptoms, how would your lifestyle change? And of course "Which sporting activities would you start with"? Before we plan an operation, I look for the answer to the question of whether the patient has had severe pain for a long time. Are there restricted mobility abilities?

Not for a day, not for a week, but for a longer period of time, which was unsuccessfully combated by sufficiently intensive conservative therapy. If the answer is yes, then the expectations for this joint are relatively clear. We can predict that the symptoms will persist over time and mostly get worse. Then comes the next question: "When should we schedule the operation?" The appropriate time should be chosen according to the patient's general condition, work, activities and rest.

Moderator: How long should we try conservative treatment before deciding to have surgery?

S.T.: Most people come to me after trying conservative therapy for a long time, sometimes years. They tried almost all non-surgical measures, alternative medicine, consulted with other colleagues. They received an appropriate assessment for the surgical treatment. They've tried physical therapy, conditioning programs, some form of drug therapy, hyaluronic acid injections, PRP, corticosteroids, and more. In this case, the decision is easier because the alternatives have been exhausted.

Moderator: 12 months of therapy before you see her again?

S.T.: I would say it depends on the clinical symptoms you have. Osteoarthritis most commonly occurs in two ways.

In the first case, the patient has had complaints for many years. They are mild, the patient is informed about his condition, the course of the disease and the type of surgical intervention. The disease has a progressive course, symptomatic and asymptomatic periods alternate. Patients receive pain-relieving therapy that works. You recognize a moderate course of the disease. At some point they say to themselves "Now it's a problem".

In the second type, we have a long asymptomatic period, after which there is a sudden onset of pain and stiffness that gradually subsides. This is typical of an avascular necrosis of the hip joint (Chandler's disease). These are mostly younger patients who have been fully active, walking and jogging without symptoms. Upon further discussion, some recall short, sporadic periods of pain in the past that were unrecognized signs that a problem was occurring. They find it difficult to accept their diagnosis. In this type of patients, due to the degree and extent of functional impairment, degenerative process, we may need to reduce the operation time. However, we must try conservative treatment. But after a few months of being unsuccessful, I would say it's time to start planning for a joint replacement.

Is the night pain related to the "timing" of the operation?

Yes, the first clinical symptoms of arthritic changes are usually dull groin pain, usually in the anterior thigh. Jokes increase during flexion (bending the limb toward the body).

With isolated damage to the labrum of the joint, a cartilage defect, the pain is well localized by the patient. As the disease progresses, we observe pain in an adjacent area: the thigh, the buttocks; then I would say it is advanced arthrosis changes.

Pain at night while resting is a sign of advanced arthritic changes. It can also occur with isolated small segment cartilage damage, but awakening from groin pain usually occurs with advanced osteoarthritis. Other diseases are also associated with night pains, which are included in the differential diagnosis of coxarthrosis.

Moderator: The other aspect that is often mentioned is age.

Yes, this topic is discussed frequently and views on the subject have changed over the last 25 years. With the improvement of implants in the last 30 years and especially with the improvement of their coverage, the trend is toward replacement after a much longer period of time. In young patients, in addition to the appropriate implant selection, a surgical approach should be considered, which is minimally invasive, anterior, Roettinger, etc., and would be more suitable for an early active postoperative rehabilitation protocol.

How do I choose a suitable implant?

I would say that the guide for choosing an implant is the quality of the bone, the type of pathology and the general condition of the patient, not so much the age.

Stefan Tserovski completed his school education at the 91st German Language High School in 2009. In 2016 he graduated from Medical University - Sofia. In 2019 he defended a dissertation on "Surgical dislocation of the hip joint in children and adolescents". He is currently a specialist in "Orthopaedics and Traumatology" at USBALO "Prof. Boycho Boychev” and assistant at the Medical University - Sofia, where he is actively engaged in teaching. He is the author of over 20 scientific papers. The team www.ortoped.bg

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